Osteoporosis is a disease that weakens bones, increasing the risk of sudden and unexpected fractures. Literally meaning "porous bone," it results in an increased loss of bone mass and strength. The disease often progresses without any symptoms or pain. Generally, osteoporosis is not discovered until weakened bones cause painful fractures (bone breakage) usually in the back (causing chronic back pain) or hips. Unfortunately, once you have an osteoporotic fracture, you are at high risk of having another. These fractures can be debilitating. Fortunately, there are steps you can take to prevent osteoporosis from ever occurring. Treatments can also slow the rate of bone loss if you have osteoporosis.
What causes osteoporosis?
Though we do not know the exact cause of osteoporosis, we do know how the disease develops. Your bones are made of living, growing tissue. An outer shell of cortical or dense bone encases trabecular bone, a sponge-like bone. When a bone is weakened by osteoporosis, the "holes" in the "sponge" grow larger and more numerous, weakening the internal structure of the bone.
Until about age 30, a person normally builds more bone than he or she loses. After age 35, bone breakdown outpaces bone buildup, resulting in a gradual loss of bone mass. Once this loss of bone reaches a certain point, a person has osteoporosis.
How is osteoporosis related to menopause?
There is a direct relationship between the lack of estrogen after menopause and the development of osteoporosis. After menopause, bone resorption (breakdown) outpaces the building of new bone. Early menopause (before age 45) and any prolonged periods in which hormone levels are low and menstrual periods are absent or infrequent can cause loss of bone mass.
What are the symptoms of osteoporosis?
Osteoporosis is often called the "silent disease" because bone loss occurs without symptoms. People may not know that they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a fracture or a vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as stooped posture.
Who gets osteoporosis?
Important risk factors for osteoporosis include:
- Age. After maximum bone density and strength is reached (generally around age 30), bone mass begins to naturally decline with age.
- Gender. Women over the age of 50 have the greatest risk of developing osteoporosis. In fact, women are four times more likely than men to develop osteoporosis. Women’s lighter, thinner bones and longer life spans account for some of the reasons why they are at high risk for osteoporosis.
- Race. Research has shown that Caucasian and Asian women are more likely to develop osteoporosis. Additionally, hip fractures are twice as likely to occur in Caucasian women as in black women. However, women of color are more likely to die after a hip fracture.
- Bone structure and body weight. Petite and thin women have a greater risk of developing osteoporosis because they have less bone to lose than women with more body weight and larger frames. Similarly, small-boned, thin men are at greater risk than men with larger frames and more body weight.
- Family history. Heredity is one of the most important risk factors for osteoporosis. If your parents or grandparents have had any signs of osteoporosis, such as a fractured hip after a minor fall, you may be at greater risk of developing the disease.
How can I know if I have osteoporosis?
A painless and accurate test can provide information about your bone health before problems begin. Bone mineral density (BMD) tests, or bone measurements, are X-rays that use very small amounts of radiation to determine bone density. In addition to assessing bone health, the test can determine the severity of any osteoporosis.
Please note that women with no other risk factors whose BMD T-scores are below -2.5 should begin therapy to reduce the risk of fractures. (T-scores compare a person’s BMD to the optimal or peak density of a healthy 30-year-old woman to determine fracture risk.) Women with BMD T-scores below -1.5 and who have other risk factors should also consider beginning therapy to reduce the risk of fractures.
Who should have a bone mineral density test?
- All post-menopausal women who suffer a fracture.
- All post-menopausal women under age 65 who have one or more additional risk factors.
- All post-menopausal women age 65 and over, regardless of additional risk factors.
How is osteoporosis treated?
Treatments for established osteoporosis (meaning, you have osteoporosis) include:
- Calcium and vitamin D supplements
- Medications such as risedronate (Actonel®, Atelvia®), ibandronate (Boniva®), raloxifene (Evista®), alendronate (Fosamax®), zoledronic acid (Reclast®)
- Calcitonin (Fortical®, Miacalcin®,)
- Denosumab (Prolia®) (twice a year antibody therapy)
- Estrogen therapy
- Weight-bearing exercises (which make your muscles work against gravity)
- Injectable teriparatide (Forteo®) (bone-building agent)
Should I consider hormone therapy?
Hormone therapy (HT) is believed to be useful in preventing or alleviating the increased rate of bone loss that leads to osteoporosis. It is generally recommended for postmenopausal women who:
- Undergo an early menopause
- Have a low bone mass, as measured by a bone-density test and menopausal symptoms
- Have several other risk factors for osteoporosis, such as: a petite, thin frame; family history of osteoporosis, or a medical problem associated with osteoporosis
While all of the risks associated with HT are not yet known, studies have shown that some types of HT may increase your risk of developing:
- Breast cancer
- Gallbladder disease
- Blood clots
- High blood pressure in some women
If you are using HT for osteoporosis prevention, be sure to talk to your doctor so you can weigh the benefits of HT against your personal risk for heart attack, stroke, blood clots and breast cancer. If needed, your doctor can prescribe different treatments to prevent osteoporosis and fractures.
Finally, it’s important to note that women who have had their uterus removed by hysterectomy are prescribed estrogen alone, not the combination of hormones found in HT. Estrogen therapy alone has been shown to have less risk than combination hormone therapy. Your doctor can provide you more information about how your individual health history fits in with the risks and benefits of hormone therapy.
Are there alternatives to HT?
For those women who cannot take HT for health reasons or choose not to because of personal reasons, there are alternatives, including:
- Fosamax, Actonel, Atelvia, Boniva. These drugs belong to a class of drugs called bisphosphonates, which prevent bone breakdown. They are used to prevent and treat osteoporosis. They have been shown to slow bone loss, increase bone density, and reduce the risk of spine and non-spine fractures. They may be considered in postmenopausal women who are at risk of developing osteoporosis and for whom the desired clinical outcome is to maintain bone mass and to reduce the risk of fracture. Boniva is also available in IV form, given every 3 months via a nurse visit. Atelvia is a weekly delayed-release formulation which eliminates the need to take the medication on an empty stomach.
- Fortical, Miacalcin. These drugs are made up of a naturally occurring hormone, called calcitonin, involved in calcium regulation and bone metabolism. In women who are at least five years beyond menopause, it slows bone loss and increases spinal bone density in women who have osteoporosis. Women report that it also eases pain associated with bone fractures. However, this medication is rarely used anymore due to very limited studies about its effectiveness.
- Evista. This drug is a selective estrogen receptor modulator (SERM) that has many estrogen-like properties (and some anti-estrogen properties depending on the body organ affected). It is approved for prevention and treatment of osteoporosis and can prevent bone loss at the spine, hip, and other areas of the body. Studies have shown that it can decrease the rate of vertebral fractures by 30 to 50 percent. It has the same risk of blood clots as hormone therapy. This medication has been shown to decrease breast cancer risk.
- Reclast. This is an IV bisphosphonate therapy that can be given once yearly to treat osteoporosis, or once every other year for prevention in patients with osteopenia. It is a good alternative in patients who do not tolerate oral bisphosphonates. It reduces bone loss, and reduces the risk of both spine and hip fractures.
- Prolia. This is an antibody that helps stop the development of bone removing cells before they cause bone loss. It is given as a twice a year injection at a doctor’s office. Patients taking Prolia might be at increased risk for infection.
How can I prevent osteoporosis?
There are a variety of ways you can protect yourself against osteoporosis, including:
- Exercise. Establish a regular exercise program. Exercise makes bones and muscles stronger and helps prevent bone loss. It also helps you stay active and mobile. Weight-bearing exercises, done three to four times a week, are best for preventing osteoporosis. Walking, jogging, playing tennis, and dancing are all good weight-bearing exercises. In addition, strength and balance exercises may help you avoid falls, decreasing your chance of breaking a bone.
- Eat foods high in calcium. Getting enough calcium throughout your life helps to build and keep strong bones. The U.S. recommended daily allowance (RDA) for calcium for people age 31 to 50 is 1,200 mg (milligrams) each day. People over 50 should get 1,500 mg of calcium each day. Excellent sources of calcium are milk and dairy products (low-fat versions are recommended); a variety of seafood, such as canned fish with bones like salmon and sardines; dark green leafy vegetables, such as kale, collards and broccoli; calcium-fortified orange juice; and breads made with calcium-fortified flour. Supplements. If you think you need to take a supplement to get enough calcium, check with your doctor first. Calcium carbonate and calcium citrate are good forms of calcium supplements. Be careful not to get more than 2,000 mg of calcium a day very often. That amount can increase your chance of developing kidney problems.
- Vitamin D. Your body uses vitamin D to absorb calcium. Being out in the sun for a total of about 20 minutes every day helps most people’s bodies make enough vitamin D. You can also get vitamin D from eggs, fatty fish like salmon, cereal and milk fortified with vitamin D, as well as from supplements. People over age 50 should ingest at least 1000- 2000 IU. More than 10,000 IU of vitamin D each day is not recommended (unless recommended by your provider) because it may harm your liver and even lower bone mass.
- Estrogen. Estrogen, a hormone produced by the ovaries, helps protect against bone loss. Replacing estrogen lost after menopause (when the ovaries stop most of their production of estrogen) slows bone loss and improves the body's absorption and retention of calcium. But, because estrogen therapy carries risks, it is only recommended for women at high risk for osteoporosis who have other reasons, like menopausal symptoms. To learn more, talk to your doctor about the pros and cons of estrogen therapy.
- Avoid certain medications. Steroids, certain drugs used to treat seizures (anticonvulsants), blood thinners (anticoagulants), and thyroid medications increase the rate of bone loss if not used as directed. If you are taking any of these medications, speak with your doctor about how to reduce your risk of bone loss through diet and lifestyle changes.
- Other preventive steps. Limit alcohol consumption and do not smoke. Smoking causes your body to make less estrogen, which protects the bones. Too much alcohol can damage your bones and increase your risk of falling and breaking a bone.
How can I get the calcium my body needs if I'm lactose intolerant?
If you are lactose intolerant, or have difficulty digesting milk, you may not be getting enough calcium in your diet. Although most dairy products may be intolerable, some yogurt and hard cheeses might be digestible. You can also eat lactose-containing food by first treating it with commercial preparations of lactase (which can be added as drops or taken as pills). There are also lactose-free dairy products you can buy. You can also eat lactose-free foods high in calcium, such as leafy green vegetables, salmon, and broccoli.
What's the role of vitamin D in preventing osteoporosis?
Your body uses vitamin D to absorb calcium. The recommended daily allowance of vitamin D is 1000 to 2000 IU. It can be obtained from about 20 minutes of sunlight, from drinking fortified milk, and from supplements.
While vitamin D is essential for all-around good health, too much of the vitamin may result in excessive amounts of calcium in the blood and urine, which can result in kidney stones and possible blood loss.
What are weight-bearing exercises and how do they help strengthen bone?
Weight-bearing exercises are activities that make your muscles work against gravity. Walking, hiking, stair climbing, and jogging are all weight-bearing exercises that help build strong bones. Thirty minutes of regular exercise (at least 4 days a week or every other day) along with a healthy diet may increase peak bone mass in younger people. Older women and men who engage in regular exercise may experience decreased bone loss or even increased bone mass.
What can I do to protect myself from fractures if I have osteoporosis?
If you have osteoporosis, it is important to protect yourself against accidental falls, which may result in fractures. Take the following precautions to make your home safe:
- Remove loose household items, keeping your home free of clutter.
- Install grab bars on tub and shower walls and beside toilets.
- Install proper lighting.
- Apply treads to floors and remove throw rugs.
- Buy hip pad protectors.
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